Home Health Community Urges Cms To Root Out Fraudulent ‘bad Actors’

On Wednesday, four major home-based care associations wrote a letter to Dr. Mehmet Oz, the administrator of ​the ​Centers for Medicare and Medicaid Services (CMS), lauded CMS’ efforts to root out fraud, waste and abuse – while calling for the agency to protect compliant providers.

The letter, signed by the National Alliance for Care at Home (the Alliance), LeadingAge, LeadingAge California and the California Association for Health Services at Home (CAHSAH), said recent media coverage and federal enforcement have rightly focused on home health and hospice fraud, but that the fraud “crisis” is the result of a subset of bad actors. 

“The overwhelming majority of providers serve their communities with integrity,” the letter wrote. “Any federal response must be carefully targeted to protect patients and preserve access to high-quality care from providers who have earned the trust of the families they serve.”

The signing organizations represent over 1,500 hospice and home health providers with over 10,000 locations.

Specifically, the letter called for CMS to continue and expand its site visits to high-risk areas, saying that boots-on-the-ground oversight is one of the best deterrents to fraud. CMS leaders, including Dr. Oz, recently took this on-the-ground approach when visiting home health and hospice fraud hotspots in Nevada and California. 

The organizations also wrote that they supported the use of the Provisional Period of Enhanced Oversight (PPEO) and Enhanced Prepayment Reviews (EPR) to identify and address fraudulent billing before funds are improperly paid. The organizations also cautioned that the applications of these tools should not hinder compliant providers.

“The goal of these tools must be clearly and consistently framed around catching fraud, not reducing the number of providers, whether fraudulent or not,” the letter read. “Compliant providers, often longstanding participants in the Medicare program, who undergo a change of ownership should not face enhanced burdens designed for bad actors. We encourage CMS to better target these tools using a risk-based approach focused on new providers and recent entrants, billing patterns, referral relationships, ownership structures, and other fraud indicators that would allow CMS to focus its resources where they are most needed and reduce the burden on compliant providers.”

The organizations made several other recommendations to CMS, including encouraging the agency to partner with state licensing agencies to “provide additional review and scrutiny for an applicant for state licensure before enrollment in Medicare is even an option.”

Also among the letter’s suggestions was the recommendation that CMS closely evaluate reviews and approvals of enrollment applications and consider requiring additional documentation, in order to prevent fraudulent providers from entering the Medicare program.

The signing organizations also specified that they are actively working to develop a set of additional recommendations in response to the Administration’s Request for Information (RFI) Related to

Comprehensive Regulations To Uncover Suspicious Healthcare (CRUSH).

The encouragement of CMS’ focus on fraud, while cautioning against a “broad brush” when doing so, aligns with previous comments from Jennifer Sheets, the CEO of the National Alliance for Care at Home (the Alliance). 

In a Wednesday statement, Sheets said the Alliance commends CMS for its focus on fraud. 

“As these critical efforts continue, we must consider the downstream effects on reputable providers and the people they care for,” Sheets said. “Heightened oversight and added administrative complexity may cause physicians and practitioners to think twice about making referrals, and families, already navigating difficult decisions, could feel increased hesitation if messaging around bad actors overshadows the broader reality of high-quality care.”

Katie Smith Sloan, the president and CEO of LeadingAge, the association of nonprofit and mission-driven providers of aging services, said that program integrity is critical, but that compliant providers must also be acknowledged and supported.

“Gross overgeneralizations about the home health and hospice sectors unnecessarily undermine trust and do a disservice to the vast majority of providers who deliver compassionate, compliant care each day,” Sloan said. “We urge CMS to take a strong and balanced approach to enforcement.”

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